Dear Sally
Can I suggest you email Sara Wickham who has a chapter written in her book
abt not doing VE's in labour written by Lesley Hobbs may be helpful to get
some research sent to you asap [EMAIL PROTECTED]
also on the gentle birth website (also pasted below) are some links to
research on the external signs of assessing dilation
http://www.gentlebirth.org/archives/birth.html#Dilation
good luck
sally-anne
Assessing Dilation from External Signs
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Assessing Dilation from External Signs
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To VE or not to VE? That is the question from the Association of Radical
Midwives
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I think it's a rare instance where one needs to assess dilation in order to
provide appropriate care. Eventually, she'll either feel an urge to push or
you'll see the head between her legs.
--------------------------------------------------------------------------------
I'll be working as a doula with a client who has an abuse history and wants
to avoid all vaginal exams in labor. What can I do if the nurses become
insistent about assessing cervical dilation?
--------------------------------------------------------------------------------
In general, hospital nurses are clueless about external signs because
they're not used to watching the labor progress. They arrive and leave at
random points in the labor, and they only know how to assess dilation by
checking the cervix.
When I'm labor coaching at a hospital birth, where cervical exams are
generally off limits to me as the labor coach, I look first at the
contraction pattern, then dilation bleeding, then early decels to reflect
coming up against the resistance from the pelvic floor, then movement of the
location of the heart (having a mechanical fetoscope is best for this) to
reflect descent/rotation, and then expect an urge to push.
I would be prepared to study up on the alternative techniques and then bluff
your way like crazy that you really can assess dilation that way, start your
estimate on the low side, make regular progress, and do everything you can
to make sure she gets to the "urge to push" phase before they get too
curious.
And remind the client that she can always say no. Ideally, she will have
discussed this with her care provider and it will be charted that no vaginal
exams are to be done for the first twelve hours, or something like that.
Get clear guidelines from your client, and remind them that touching her
without her consent is criminal assault.
--------------------------------------------------------------------------------
At the initial exam, I let them know when and how many standard vag exams
women have and then explain that many women, however, choose to have two...
one for the PAP and one when the membranes rupture. I let her decide how
many she wants, but that two is the minimum.
During the 3rd Tri, reminding her again about the vaginal exam when her
membranes rupture (or if she chooses, when she arrives, when membranes
rupture, urge to push, etc.).
--------------------------------------------------------------------------------
Why? We see many clients who for religious reasons refuse vaginal exams; so
we don' t do them. We explain the "usual" of course, and that VEs may help
by giving additional info in certain instances -- -- but if a mom wants to
refuse a VE, Pap, etc; then why not go along with her wishes?.
If we listen to heart rate when membranes rupture --the FHTs will tell us if
there is a problem with the cord. (which is unlikely anyway if she is full
term and vertex).
If she has the urge to push and can't stop pushing then let her push -- you
will either see the baby soon, or she will get discouraged and stop pushing.
This is an easy call! Vaginal exams in labor are almost never REALLY
necessary! Watch mom and baby from the outside -- outward signs/symptoms of
progress in labor are pretty reliable.
--------------------------------------------------------------------------------
A research study in 1997 hypothesized that the purple line that creeps up
the natal cleft can be an indicator of cervical dilatation. The line begins
at the anal margin at the start of labour and rises like a mercury
thermometer. When it reaches the top, the woman is fully.
Lancet 1990 Jan 13;335(8681):122
Clinical method for evaluating progress in first stage of labour.
Byrne DL, Edmonds DK
A midwife, Lesley Hobbs, has just published an article in the Practicising
Midwife(1998) 1:11, and she is finding this a quite reliable indicator of
cervical dilation (after much practice) She gives a diagram of the various
dilatations but you'll have to access the article to see it.
The natal cleft begins at the anal margin running towards the sacrum.
--------------------------------------------------------------------------------
The original research behind this has never been published in full but was
summarised in a letter to the Lancet (reference below).
The authors propose that an "increase in intrapelvic pressure causes
congestion in the ... veins around the sacrum, which, in conjunction with
the lack of subcutaneous tissue over the sacrum, results in this line of red
purple discoloration".
In personal correspondence Dominic Byrne (co-author of the study) pointed
out that different skin colours make identification of the red line
variable.
Lesley Hobbs article in the Practising Midwife also appears in Sara
Wickham's "Midwifery Best Practice (reference below). It includes a diagram
of the direction of the line illustrating its ascent in centimetres. In
fact, in the original study, centimetres were not used. Instead Byrne
divided the distance from anus to nape of buttocks (which he didn't define
exactly) into tenths. I have no idea if that is on average 10 cms as I
haven't measured!!
I've been using this as a marker of dilatation for the past year and it does
seem pretty consistent.
Byrne DL and Edmonds DK (1990) Clinical method for evaluating progress in
first stage of labour in The Lancet Vol 335 No 8681 p122
Hobbs L (2003) Assessing cervical dilatation: Watching the purple line in
Wickham S (Ed) Midwifery: Best Practice, Books for Midwives, Edinburgh Ch
4.3 p77-8
--------------------------------------------------------------------------------
In Polly's Birth Book, it mentions a point on the sole of the foot that can
be used to tell once a woman has reached 5 cm. Apparently, if you look at
the bottom of the foot with the toes pointing up, the spot "above" the heel,
center, will tighten and release as the uterus contracts IF she is at least
at 5 cm.
And, a midwife I know who attended one of my births told me, as I did this
uncomfortable thing, that if a woman's water breaks and she pukes at the
same time, that's "The 7 cm Stretch".
--------------------------------------------------------------------------------
I don't like to check for cervix at full dilation because it's so hard on
the Mom to have an exam then and cervix can be missed and pushing begun too
early. I think it's artificial to think there is a first and second stage.
There should be a fluid flow of the phases together.
Here are my indicators of full dilation:
1.. passing stool involuntarily. (We say, around here, where there's s--t
there's usually a little head not far behind it).
2.. bearing down begins at the beginning of the contraction and not just
at the height of it.
3.. head visible at the perineum (I know that sounds obvious but I have
heard European midwives say they are taught that is the ONLY way you can be
sure of full dilation. Assume there is still cervix until you see a bit of
head at the introitus.
--------------------------------------------------------------------------------
I have on several occasions seen head visible on the perineum with a large
anterior lip of cervix in front of it. This is not an assurance of full
dilation. Usually the lip disappears once the head rotates to OA, but it is
a sign that that rotation needs to be facilitated.
--------------------------------------------------------------------------------
Please describe how do you facilitate rotation in this circumstance?
--------------------------------------------------------------------------------
Usually by rolling the mother from side to side. A few contractions on one
side, usually in exaggerated Sims, then a few on the other, and try to get
her to push as little as possible during this time (little grunts or blows
only to take the edge off). Generally does the trick.
--------------------------------------------------------------------------------
Assessing Dilation from Xyphoid/Fundal Distance
The contracting uterus swells upwards as it pulls in the dilating cervix.
Before a woman begins to dilate and is about at term, you can get about 5
finger-breadths of measurement between the fundus and the tip of the
breastbone (xyphoid). As she dilates, this measurement decreases at about 2
cms per finger-breatdh. At the described point in my sister's labor, I
could only get about 1 1/2 finger-breadths between these two points. So
that would be equal to 7-8 cms. dilatation. It's an old trick I learned
several years ago. It's been discussed on the doula list before but I think
it's been a while. It really works but, like vag exams, it takes practice.
Unlike vag exams, it's not out of the scope of practice as a doula to do
this type of exam because it's not done internally and not "really"
considered a clinical test.
--------------------------------------------------------------------------------
Well, I can see this might be helpful for some labors, but not for all, for
a couple of compounding reasons...
Yes, the fundus does become thick and elongated and does seem to rise during
many labors (the fundus thickens as it "takes up" the cervix -- the cervix
and lower uterine segment become thin). The uterus elongates -- thins from
side to side -- and you can see this in some labors. It's a sign of a
progressing labor -- though it can also be a sign of obstructed labor.
In the usual case though, the baby is also descending into the pelvis during
the dilation phase of labor -- so even though the fundus is getting thicker
(and a bit higher) the uterus itself is dropping as the baby descends, the
vertex flexes, the baby becomes compacted, and maybe the bag of water
breaks. All of these factors could mask the rise in fundal height, but it
might be something to keep an eye on --- It might be more accurate in
multips than in primips since multips often don't have descent until second
stage begins.
There are a couple of old methods of assessing dilation through abdominal
signs. One which is pretty accurate for late dilation is that thin line or
"crease' above the symphysis. It's visible in most moms unless they carry a
lot of abdominal weight. As labor progresses and the baby descends with
increasing dilation, the line/crease becomes wider side to side. Near
transition it is usually about three-quarters of the way across. When the
begins to slip through the cervix and settles into the birth canal it is
usually almost all the way across. It's a sign that mom is gonna start
pushing REALLY SOON!
--------------------------------------------------------------------------------
Avoiding Vaginal Exams for Abuse Survivor at a Hospital Birth
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
Assessing Descent from External Signs
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Paper on Fifths: Crichton,D S. Afr. Med. J., 48:784-787,1974 It is entitled
"A reliable method of establishing the level of the fetal head in
obstetrics."
--------------------------------------------------------------------------------
I think one of the best skills to develop as a midwife, is being able to
gauge progress of a labor without doing VEs.
--------------------------------------------------------------------------------
I recently had a baby in Australia, and VEs are rarely done in labour over
there, even in hospitals. There is nothing routine about it. How come it's
treated as a "given" In American birth practice?
I'm sure it's a valuable diagnostic tool in many cases, and important
technical skill to learn. But unless there is some exceptional reason for
it, I sure don't want it in labour.
--------------------------------------------------------------------------------
You can assess descent fairly well by watching the crease that forms
parallel to the symphysis. In a lean mom, you might not have any crease at
all at the beginning of labor, but the line gets wider as labor progresses
and it should be nearly fully across at fill dilation. Can't always see it
if mom is real heavy, but it is pretty dang reliable.
I think it's caused as the bulk of the baby's shoulders come closer to the
symphysis.
--------------------------------------------------------------------------------
----- Original Message -----
From: <[EMAIL PROTECTED]>
To: <ozmidwifery@acegraphics.com.au>
Cc: "Renee Adair" <[EMAIL PROTECTED]>
Sent: Thursday, August 31, 2006 2:14 PM
Subject: RE: [ozmidwifery] Vaginal examinations
Hi everyone,
I really need some constructive advice here...if we can't garner enough
evidence, (we are doing a lit search as well) women at Casey Hospital will
be subjected to unnecessary VEs which midwives will be obliged to perform
to remain inside Southern Health Clinical Guidelines.
Thanks
Sally
---- Renee Adair <[EMAIL PROTECTED]> wrote:
Count me in also please.
I can be emailed at [EMAIL PROTECTED]
Much thanks,
Renee
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED] Behalf Of nunyara
Sent: Thursday, 31 August 2006 12:55 PM
To: ozmidwifery@acegraphics.com.au
Subject: RE: [ozmidwifery] Vaginal examinations
Me as well, please!!
I am a Naturopath specialising in Fertility care and Doula in training so
if
you could send the picture to [EMAIL PROTECTED] it would be much
appreciated.
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED] On Behalf Of lisa chalmers
Sent: Thursday, 31 August 2006 11:02 AM
To: ozmidwifery@acegraphics.com.au
Subject: Re: [ozmidwifery] Vaginal examinations
Me please!!
Am in the middle of training doulas and was trying to explain to them
what
it looks like..
Thankyou!!
[EMAIL PROTECTED]
----- Original Message -----
From: "Jo Watson" <[EMAIL PROTECTED]>
To: <ozmidwifery@acegraphics.com.au>
Sent: Thursday, August 31, 2006 8:42 AM
Subject: Re: [ozmidwifery] Vaginal examinations
> Sure. Just don't look at my butt ;) There are no attachments allowed
> on
> this mailing list, am I right?
> I guess I can just email it to those who ask to see it.
>
> :)
>
> Jo
>
> On 31/08/2006, at 7:07 AM, meg wrote:
>
>> Can we see it?
>> Megan
>>
>> ----- Original Message ----- From: "Jo Watson"
>> <[EMAIL PROTECTED]>
>> To: <ozmidwifery@acegraphics.com.au>
>> Sent: Wednesday, August 30, 2006 11:49 PM
>> Subject: Re: [ozmidwifery] Vaginal examinations
>>
>>
>>> Two words:
>>> PURPLE LINE
>>> I have a great photo of mine (thanks for pointing it out, Mary!)
>>> :)
>>> Jo
>>> On 30/08/2006, at 9:31 PM, Sally @ home wrote:
>>>> Just to add to this...
>>>> There was an extremely heated discussion at a meeting with docs and
>>>> midwives where I work about how doing a VE is the only way to
>>>> ascertain progress in the normal labour of uncompromised healthy
>>>> women. The midwives now have to come up with evidence showing that
>>>> doing a VE within 1- 4 hours of admission to hospital (then 4-6
>>>> hourly thereafter) is not necessary as we are able to assess
>>>> progress
>>>> in different ways (all of which have been poo-pooed by the
>>>> medicos)...so...am needing the help of all you wonderfully wise
>>>> women
>>>> out there.
>>>>
>>>> Thanks in advance.
>>>>
>>>> Sally
>>>> ----- Original Message ----- From: "Sally @ home"
>>>> <[EMAIL PROTECTED]>
>>>> To: <ozmidwifery@acegraphics.com.au>
>>>> Sent: Tuesday, August 29, 2006 10:30 PM
>>>> Subject: [ozmidwifery] Vaginal examinations
>>>>
>>>>
>>>>> Was wondering what guidelines others worked with regarding when to
>>>>> do vaginal examinations...specifically in the hospital setting.
>>>>> And
>>>>> what evidence they base their practice on.
>>>>>
>>>>> Thanks in advance.
>>>>>
>>>>> Sally
>>>>> --
>>>>> This mailing list is sponsored by ACE Graphics.
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>>>>>
>>>>>
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>>>>>
>>>>
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>>>>
>>> --
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>
>
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